Tuesday, July 29, 2008

Now, I am not much of a "reductivist," in that I don't believe that people's personalities can be neatly decoded based on their political philosophies. What people feel about the proper role of government does not necessarily translate to how they may view private interactions. For example, although I am a libertarian, I am an ardent proponent of private charity and volunteerism, and I abhor the notion of "Social Darwinism." However, I do wonder whether or not libertarian doctors may tend to approach clinical situations a bit differently than do other physicians. I'll use an example from medical school.

In Los Angeles, we have tons of under-employed actors. When they aren't discussing the Stanislavsky method at Psychobabble, many come to our medical school to act as "standardized patients" or "SPs" They are given a scenario, in which they must pretend to be the dying/angry/unknowingly-HIV-infected patient, and we med student poindexters must learn how to speak with them properly. We usually have a tag-team approach, in that one student will start the "interview" until our professor calls "time-out." We then provide feedback to the student on how the interaction went, until the next student goes, taking over as the "same medical student."

One time we had an SP whose scenario is described as follows, (The patient does not really exist and is a caricature):

PAUL CASSIDYPaul Cassidy is a computer engineer, now off work on disability, who is coming to the orthopaedic clinic today for another opinion about his chronic low back pain. He has agreed to talk to a medical student about his history before seeing the attending physician. Two years ago, he was in a car accident in which 3 lumbar vertebrae were crushed (L2, L3, and L4). He underwent spinal fusion at that time and, following a lengthy hospital stay, extensive rehabilitation. He continues to have back pain that prevents him from returning to work. He is upset that his previous orthopedist has not been able to find any additional physical complications to explain his persistent and chronic pain. (He has had x-rays and CT scan recently which show no evidence of pathology beyond his post-surgical changes.) Your task is to elicit Mr. Cassidy's concerns and history. If you have some ideas about ways he can manage his pain, you may choose to explore that with him in the later part of your interview.

"Mr. Cassidy" entered indignantly, clutching his back in pain. He was clearly frustrated by his myriad previous physicians' inability to properly help him, and insistent that the doctor find the proper pathology and treatment. He tossed out his words with a bit of bitterness, but generally remained polite. He explained how, in the past few years since the injury, he has not worked, maintained any hobbies, nor visited any friends. He has since moved back in with his mother, and basically does nothing all day. He would really like to start work again, but he is just waiting for his pain to be fixed. His only source of income is his monthly disability check.

My peers treated Mr. Cassidy with respect and empathy. They said things like "that sounds really tough," "It must be so difficult to be going through such a hard time," and "we will do everything we can to try to fix this problem." They asked him about all of his symptoms, and took a detailed history of his long ordeal. I was genuinely impressed with my fellow med students, some of whom have shockingly good interviewing skills.

When it was my turn, I similarly expressed empathy for Mr. Cassidy. I understood he was angry, and didn't take it personally. I fortunately have never experienced the inconceivable misery of chronic pain. I am aware that I likely would have behaved no more congenially, had I been the one in the patient's seat. Thus, my problem with the situation was not Mr. Cassidy's anger, but his maintenance a life of chronic anticipation. He was waiting to engage in the world again after until he was healed, and everyone presumably considered it cruel to suggest to Mr. Cassidy could possibly end up living with his pain forever.

So I finally said to Mr. Cassidy,

"Sir, we are going to pore over your charts, and try to see if there's anything that may have been overlooked. We will make it a priority to find the best analgesic for your pain. However, I do want to address something that may be a bit difficult, yet necessary, as you seem to have put your life on hold since the accident. I want you to consider the possibility that the pain may never go away, and that, no matter how hard we try, we may not make any meaningful changes to reduce your pain. Pondering that possibility, do you think that you may approach life a bit differently, that you may feel motivated to resume any of your old activities?"

Anarchy struck. The patient stood up, shouting rapidly, "You're telling me, that I'm coming here, just to hear that I'm stuck with this? That I have to live like this for the rest of my life? You call yourselves doctors, and you're saying that you can't help me?"

Mr. Cassidy wasn't the only one disappointed by my performance. During feedback, My peers said that I was too harsh, that my bluntness shattered Mr. Cassidy's hope, and only further deepened his despair.

I don't disagree. But, given another chance, I would likely re-enact the scenario in the exact same way. I felt that I owed it to Mr. Cassidy to consider the full scope of potential outcomes. I don't want him to miss out on life. Without anticipating his unfortunate reaction, I would initially be more fearful of acting dishonestly with my patient, rather than allowing for unnecessary worry.

Similarly, in our scenario with the dying patient, while I mentioned that statistics can't be predictive of any individual case, I still said that I'd look up the average prognosis for someone with his condition. For the obese patient with Type II diabetes, I didn't blame the patient, but I also didn't blame industrial food manufacturers for his plight. Ultimately, I believe that empathy must be balanced with honesty, respect for the patient's autonomy, and a realistic belief in the role of personal responsibility. And I wonder if that makes me a particularly libertarian (almost) doctor.

About Me

I am a medical student in California. Disclaimer: I take patient privacy very seriously. When I talk about a 22-year-old, 5"5, 125 lb. African-American female with juvenile rheumatoid arthritis, please understand that my real patient might be a 65-year-old, 6"2, 220 lb. Caucasian patient with lung cancer. In other words, I have completely distorted the facts about my patients, and sometimes even completely made up stories. Additionally, I am not a licensed physician, and you should trust your grandma's shaman for medical advice before you trust this blog.